Age_Couch .,,.....*,,,. APPLICATION FOR SENIOR CITIZEN COUNTY TOWNSHIP YEAR
x \� PROPERTY TAX BENEFITS /� 02G
i State Form 4370$(R15/1-20) f 1bt0yl 022
suPrescribed by the Department of Local Government Finance 17 Z
File Mark
Information contained in this document is CONFIDENTIAL pursuant to IC 6-1.1-35-9.
INSTRUCTIONS: To be filed in person or by mail with the County Auditor of the county where the property is located.
Filing Date: Form must be completed and signed by December 31 and filed with the county auditor or postmarked by the following
January 5 of the calendar year in which the property taxes are first due and
Over 65 Deduction from Assessed Valuation Over 65 Circuit Breaker Credit
Name of applicant(owner or con ac buyer)
Is applicant the sole legal o e stable owner? If No,what is his/her exact share or interest? If owned with joint tenant or tenant in common,indicate with whom.
Yes ❑No
If name on record is diffe nt t an that of applicant,indicate below. Do all joint tenants or tenants in common reside the property?
Yes ❑No
IName of cont eller Has applicant owned or been buying the property unde e d contract for
Qu\ /"'�.,, _ at least one(1)year before claiming deduction? Yes ElNo
Address of contrac seller(number and street,city,state,and ZIP code) I t property in question:
Real property ❑Mobile home(/C 6-1-1-7)
Taxing district Key number/Legal description Record number Page number
O Z� 26-Iq -1 �3�(A o o . LI -O`� 6
Does applicant reside on p rty? Assessed value of the
$
individual's spouse.)See reverse for details.
Have you filed for any other de ions? If Yes, d�„ductions?
Yes El
JJ
Have you filed for deductions a other ouunty? If Yes,wh county?
❑ es 1GYNo
I/We certify under penalty of perjury that the above and foregoing information is true and correct.
xcAnstexSi naF f a titan Date(month,day,year)
Acetress applicant (number and street,city,state, ZIP code) .
Signature of authorized representative �t•^T1 Date(month,day,year)
Address of authorized representative (number and street,city,state,and ZIP code)
Sign Ate of un n ditor FILED Date(month,2- `ay1ye )� GJ- 2-or
FEB 1 2022
i`h,./z,..d c2.14 ;na)
GIBSON COUNTY AUDITOR
DISTRIBUTION: Original-County Auditor; File-Stamped Copy-Taxpayer